The Case for Mandatory Organ Donation

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The Case for Mandatory Organ Donation

A child plays in a tsunami relief camp called Ernavoor about seven miles north of Chennai. View Slideshow Curbing the illegal trade in human organs just might mean scrapping the way we think about the rights of brain-dead organ donors.

Organ brokers have already proven that they are savvy enough to skirt legal roadblocks, and their businesses will continue as the supply of available donor organs remains small and the profits high.

Increasing the supply of cadaver organs is an obvious solution, but volunteer programs have not produced enough organs to make a difference. Now some leading ethicists and doctors are re-examining the principle of informed consent in government organ-donor programs, arguing that harvesting from cadavers should be a routine procedure just like autopsies in murder investigations.

"Routine recovery would be much simpler and cheaper to implement than proposals designed to stimulate consent because there would be no need for donor registries, no need to train requestors, no need for stringent government regulation, no need to consider paying for organs, and no need for permanent public education campaigns," wrote Aaron Spital, a clinical professor at Mount Sinai School of Medicine, and James Stacey Taylor, an assistant professor of philosophy at the College of New Jersey, in a controversial article published this year by the American Society of Nephrology.

This approach faces obvious and enormous obstacles, challenging as it does widely and deeply held beliefs about the sanctity of the body, even in death. But it could be the only solution that works.

Roughly half a million people around the world suffer from kidney failure and many are willing to pay any price for a donor organ. They have two options: wait on impossibly long donation lists or pay someone for a live donor transplant.

The United Network for Organ Sharing, which runs the current system of cadaver donation in the United States, maintains lists of brain-dead patients around the country and actively tries to match up prospective donors. At present there are more than 90,000 people waiting for kidneys but only about 14,000 donors enter the system each year.

The shortage of donors isn't based on a shortage of brain-dead people in hospitals, but on the shortage of people whose organs – even after they have opted into a convoluted and difficult organ-donation program – never find their way to a viable patient. A 2005 Gallup poll revealed that more than half the population of the United States was willing to donate organs after death, but inefficiencies in the current system mean that even willing donors often end up not donating because families raise objections or there is a question about consent.

Fewer than two out of 10 families opt to donate organs of relatives after death. Hospitals often are unwilling to share organs from donors on their rolls and waste organs while waiting to set up their own in-house transplants. Often, perfectly good transplant organs get lost in a bureaucratic shuffle.

Routine organ donations would dramatically increase the supply of donor organs; with a little effort it would be possible to set up a system to transport donation-worthy organs anywhere in the world.

Once removed from a body, a kidney has a 72-hour window before it needs to be transplanted into a patient. If we use FedEx as our yardstick, with the right transportation infrastructure, that kidney can travel to any point on the globe in less than 24 hours – giving surgeons on either end of the transplant team two days to find a viable donor and perform the necessary surgery. And once regulations for transporting human organs cut though red tape, the cost of transportation would be less than a first-class plane ticket.

"Bold proposals like those posited by (Spital and Taylor) are necessary to fuel spirited debate and influence public policy. From an ethical view, much of what they have written can be supported and resonates well with some who contemplate such issues," wrote Ron Gimbel, assistant professor in the preventive medicine and biometrics department at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, in an e-mail conversation with Wired News.

Setting up a mandatory system of organ donation would undoubtedly stir protests from around the country. Americans are used to the idea of having a choice over the state of our bodies after death and many people would be irked that the government would be meddling into some of the most sensitive and private moments of a family's life.

In fact, that concept is an illusion. In cases where the cause of death is ambiguous, the government routinely conducts autopsies where large pieces of the person's viscera are removed for scientific analysis – often later to be used in a criminal investigation. In addition, as Spital and Taylor argue, the government reserves the right to draft young men against their will into war and risk their lives in combat operations.

Nancy Scheper-Hughes, a medical anthropologist at the University of California at Berkeley who has made her career writing about violence caused by poverty, stresses that the current system of organ donation breeds inequalities – but she is equally wary of a system that doesn't allow people to opt out of becoming organ donors after death.

"Why make everyone pay a body tax?" she asks. "We have 60 million people who are uninsured in this country; why should we force the people who we denied health care in their life to offer up their bodies after they die? The history of transplants has been replete with doctors who have put themselves above the law and (think) that they are ahead of the morality of the time and that society has to catch up with them," she said.

"This proposal doesn't seem to be any different," she added.

If mandatory donation is politically unfeasible now, the United States could consider an opt-out rather than the opt-in organ-donation policy, known as "presumed consent" and adopted in various guises in France, Spain, Australia, Belgium and Portugal. (At present, no country mandates that organs must be relinquished at death.)

These laws vary in their details but in general assume that someone would want to be an organ donor unless they explicitly make their objections known by registering in a national online database. Organ-donation rates in all of these countries outstrip the U.S. rates. Powerhouse transplant organizations in the Unites States like the American Kidney Fund have lobbied for this system since 2004, but have yet to make headway in national policy.

"Research shows that there would be a increase of between 16 percent to 50 percent in the availability of organs, and others have speculated that this would eliminate the shortage of organs in some categories," said Eric Johnson, professor of business at Columbia University and a proponent of presumed-consent policy.